The notice on the clinic’s website, “We do not accept Medicaid,” might as well say, “Poor people aren’t welcome here.” It’s an unfortunate practice that is sadly all too common and affects the lives of millions of Americans. My patient, Gerald, is one of them.

A retired school bus driver, Gerald and his wife make do on a meager income. For health insurance, he relies on Medicaid — insurer of the aged and disabled, pregnant women and children, and the poor. Gerald drives 50 miles into the city to see me for his diabetes. There are clinics closer to his home, of course, but he makes the long journey to see me because the clinics in his area won’t see patients with his insurance. In our health care system, beggars can’t be choosers.

The blanket refusal of many physicians to see patients with Medicaid is unjust. It contributes to a health care system of separate but equal based on social class. The medical profession must fix this glaring breach in our contract with society — all physicians should accept Medicaid.

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An oft-cited study showed that 31 percent of physicians nationwide were not willing to accept new Medicaid patients. The rate was even higher for orthopedic surgeons and dermatologists, two of the highest-paying specialties in medicine. The Affordable Care Act led to some modest improvements, particularly in access to primary care, but the acceptance rate of patients covered by Medicaid remains dismally low.

Yet these patients need us. One in 10 have cancer; 1 in 5 have diabetes; 1 in 3 have mental illness. As Paul Farmer has written, disease has a “preferential option for the poor.”

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To explain why some physicians do not accept Medicaid patients, physicians and administrators frequently blame the bureaucratic hassles of Medicaid, particularly its subpar reimbursements. Nationally, Medicaid reimburses providers for their services at 66 percent the rate of Medicare and at even lower than that compared to private insurance. So the business argument goes like this: To maximize revenue and margins, prioritize patients with private insurance and turn away those with Medicaid.

Patients with Medicaid are also often psychosocially complex, requiring more attention and resources than the average patient. Gerald, for example, can’t read, which complicates and frustrates his care. So the job satisfaction argument goes like this: To minimize encounters with difficult patients, prioritize those with private insurance and turn away those with Medicaid.

What this means for patients with Medicaid is what Seema Verma, administrator for the Centers for Medicare and Medicaid Services, decries as a “card without care.” In truth, that’s a bit misleading. Gerald does have access to care — he sees me. A survey of Medicaid enrollees found that 84 percent were able to get the care they needed. Yet to do that Gerald must drive past dozens of other clinics that will not accept Medicaid and get to a safety-net clinic that will.

Although Medicaid helps bridge the gap between those who have private insurance and those who have no insurance, physicians drive a wedge into the health care system and propagate the structural inequities of separate but equal when they turn away those with Medicaid.

A modern version of the Hippocratic oath, called “Medical Professionalism in the New Millennium: A Physician Charter,” demands that we work to “eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.” That’s only fair. In recognition of the integral role that physicians play in society, the U.S. government invests $15 billion each year in the training of doctors, or $150,000 per year on each and every resident physician. No other profession enjoys this level of public support.

To rebuff Medicaid, the insurer of society’s most underprivileged and vulnerable, is to reject our moral responsibility as physicians and to worsen the very disparities in health care we have been charged with eliminating.

While policymakers continue to work towards improving Medicaid, physicians can and must do their part to live by our collective professional ethics and help those most in need of our services. Doing so would not bankrupt our practices. Each physician can decide what level his or her practice can sustain — the answer is not zero.

Over the last few years, Medicaid and health care have become increasingly politicized. But physicians must remember that behind all the double-speak, pretense, and charades are real people like Gerald who need care. Refusing to see them is nothing less than discrimination by another name.

Sumit Agarwal, M.D., is a fellow in internal medicine at Brigham and Women’s Hospital and is pursuing a master’s degree in public health from the Harvard T.H. Chan School of Public Health.

  • This message is for Kat. I’m not sure why U of M is making your son wait for 4-5 years, I’d try calling UDN with NIH, he will need a PCP signing off on the paperwork to do a program but they help with people such as your son. U of M is taking part with UDN. Also I too had severe pain for migraines, they got so bad I lost my vision temporarily multiple times. I was placed on all kinds of things that sent me into ER’s until someone placed me on Riptizan a form of Maxalt. If your son has not tried this and unfortunately there are different manufacturers and the one that worked for me was this blue pill that tasted like peppermint you dissolve under the tongue. It’s very fast acting. Also head pain can be associated with adrenal overload or lymphatic issues. There are lymphatic medical massage therapists or a good hot stone Swedish massage therapist who may be able to relieve some of the pain although these are not cures. I was told by a neurologist that untreated migraine will only get progressively worse and can cause blindness so it’s imperative you find someone to help especially if your son is experiencing halos or eye sight issues. Hope this helps and good luck. By the way I’m not a medical doctor, I’m merely stating what I have experienced and what has helped me, this is by no means medical advise just a thought to approach to take to find help from your doctors.

    • Thanks for the response. That’s what they told me when I asked about an appointment for my adult son. Four to five years. I hope when they see what he’s been through the last 18 years, they’ll change their minds. I have records, lists of all that has been done, but everyone keeps telling us to go to Cleveland Clinic. I’m getting too old for trips like that. Thank you for the encouragement. This keeps getting more difficult all the time.

  • I appreciate your comments, Tim. I am a primary care provider. I have seen many patients for free or for the little that some (not all) insurance companies reimburse. And that almost ruined me. I doubt that anyone would allow their employer to work them without pay. I doubt that anyone would agree to be paid a price for work and then sit quietly as that payment is refused because of a technicality. The healthcare payment system is broken. And, yes, there are greedy doctors in the world. But I know far more caring doctors that just want to take care of patients. We can’t do that if we are out of business.

    The article mentions that Medicaid patients tend to require more care (makes since as patients on disability often have this form of healthcare payment). To me that means we need to provide substantial incentives for those who see Medicaid patients. Who would choose to do more work for less money if a choice existed? Apparently not a majority of doctors – and I suspect not most people. While I appreciate being viewed in a special category, doctors are people – often with families and obligations. While I expect no one to feel sorry for docs, I also don’t expect them to ask doctors to do something they would not do. Again, we are people.

    So what to do? Certainly not as Joey C says. First of all, fines and penalties have been in place for years. All it did was cause people to leave medicine, practice elsewhere or take cash only for services. Telling a group of high achievers that you will force them into career slavery will definitely not work in a democracy. I think that making Medicaid worth the provider’s while is essential. Maybe reimbursement can’t go up, but what about tax protection or licensing stipends. Safety net systems often provide student loan pay off for doctors. What if that could be extended to private physicians who see enough Medicaid patients to qualify? We are a nation of innovative creators. Solutions are well within our reach if we put aside our prejudice and work together to meet the needs of all involved.

  • My son was released from a migraine clinic that he had been going to for years because he has Medicaid. He also has Medicare and Blue Cross supplemental. They are dropping all Medicaid patients, claiming they can’t bill them for anything. My son’s bills were always paid. We just applied to U of M, but there is a four to five year wait to see their migraine specialist. I’m not sure what he’s going to do. On a scale of 1-10, his migraines are between 7-10 all the time. Our next choice is Diamond Clinic in Chicago, but I’m getting too old for this!

  • I’ve been discriminated against from
    My primary doctor and 2 of my
    Specialist. I didn’t want Medicaid. But
    Being disabled I had no choice. I think
    It’s ignorance of all Phycians for what
    They’re doing to people like myself.

  • Unlike welfare recipients, doctors spend years in school, have 250K to 500K in student loans and work a highly demanding high pace day to get paid hundreds of thousands of dollars. Joey C is obviously not a physician, most likely an entitled individual that perhaps should get a real job.

  • What is it that is so hard to understand? The designers of health care don’t care about you, particularly if you have Medicaid. Medicare is falling apart as well. It has been turned into a vehicle to process more lines of revenue and the highest reimbursements into profits.

    Those doing well with the financial design changes do not care what happens to primary care. They do better by disabling primary care as they profit even more. They are doing a good job.

    Each year primary care visits are going down as the numbers in need of primary care and the demand for care and the complexity of care are going up. The declines are worse in the elderly – a direct line of blame focused on CMS with Medicare and Medicaid compromises.

    Smaller practices and practices where most needed are closing – because the financial design and regulatory changes are closing and compromising them.

    State budgets are being destroyed by the rising costs of health care. They react by compromising Medicaid – because they can get away with it.

    Wait until the next round of cuts and reforms. The Republicans have continued the meaningless and costly regulations of Obamacare and have added more costs. Wait until they cut Medicare, Medicaid, disability, and Social Security. I can almost guarantee you that the half of the nation doing worst – will be hit hardest as with the last 37 years of regulatory and policy changes.

    The Democrats bought in to the 2010 reforms that did nothing for most Americans. They did not address needed reform by increasing the payments for the basic, office, cognitive services involving generalists, general specialists, geriatricians, mental health, womens health, and basic surgical services. They failed to help this 70% of annual services. They failed to pay more where practices are already paid less.

    But they forced you to buy meaningless health insurance that does little and does not protect you in a health care disaster (high deductible, low or no coverage of primary care and mental health). Notice that this sucked many more billions away from the counties in most need – and only about 10 cents on the dollar ever returns to these places that have half enough basic workforce. Expansions of the worst public and private plans work for the insurance companies and the larger systems and practices – but not for most Americans or those fewer who remain to serve them.

    Go ahead and blame all physicians, but know that you are wasting your energy. The designers hold and manipulate all of the strings – and the media.

  • My son has been dropped by the migraine clinic he has gone to for years because he has Medicaid. They have never participated with Medicaid, but because of disability, he also has Medicare and pays through the nose for Blue Cross Supplemental. They claim they are dropping ALL their Medicaid patients because they can’t bill them for anything if they have Medicaid. I have spoken with Medicare and Medicaid and they don’t understand it either. So, now he has no doctor and is in severe pain. All we have left is out of state clinics. I’m 71 years old and that is hard on me to drive him to clinics out of state, not to mention, expensive. I don’t understand any of this.

  • Is the author of this article really a doctor? If so, I wouldn’t trust him to take care of my neighbors cat. First of all, the 150k that the government uses per resident slot is a way of subsidizing our broken public health care systems. Residents are overworked and when you consider the hourly wage it is a little above minimum wage. Also if you look at New York State, they have a huge 6 billion dollar budget deficit thanks to ineligible people enrolling in welfare which includes Medicaid. It is a broken system and needs to be reformed. It was designed as temporary safety net but unfortunately too many people decide to stay on it permanently with no incentive to better themselves.

    • Above: Tony Salerno is under the Impression the Doctors have a right to make huge salaries, that free ride ship has long sailed away. Legislation will force practices to accept Medicaid, and if they don’t they will be hit with fines and penalties, they’ll never forget. And if you can afford to still live in N.Y. You can afford It.

  • I am a Doctor who has treated medicaid patients for free many times and I never refuse a patient. That being said do some research and you will find low income people are far more likely to sue. Also consider that overhead is high and you have to make enough to pay the 5 people or so who work for you and still make a profit. Also if i do not work, I live of my savings and my overhead is still there with rent etc. The amount of time seeing a patient is far less than the paper work to document and then later bill. I believe you may want to expand your focus. On the other hand this is a very good and needed topic to review. Just expand your research and look at both sides and find solutions. One would be paperwork. Also if Medicaid patients would sign a waiver that they would not sue for a bad outcome and it be legal. At this time, even if i treat for free it does not protect from being sued even if they would sign a waiver.

    • Most Doctors are in the U.S. are making more than “a profit”. In fact they are some of the highest paid in our society. Legislation will force them to accept Medicaid and if they refuse the fines and penalties will put a hurting on them they won’t forget. The free ride of making hundreds of thousands per year is gone. And lawsuits lol?!? That’s what insurance is for. And we can’t do enough to harm the insurance companies. They misspend billions every year, another industry that’s free ride is long over.

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